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DISTANCE EDUCATION
Please complete this form if you are interested in our distance education program. All distance education students must be 21+ to participate. Fill in the fields below and someone will contact you to schedule your orientation.
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* Indicates required question
FIRST NAME
*
Your answer
LAST NAME
*
Your answer
ARE YOU 21 OR OLDER?
*
Yes
No
DATE OF BIRTH
*
MM
/
DD
/
YYYY
PHONE NUMBER (include area code)
*
Your answer
EMAIL
*
Your answer
ADDRESS
*
Your answer
CITY
*
Your answer
STATE
*
Your answer
ZIP CODE
*
Your answer
GENDER
*
Male
Female
Non-conforming/non-binary
DO YOU HAVE AT LEAST 6 HOURS EACH WEEK TO COMPLETE ASSIGNMENTS
*
Yes
No
ARE YOU ABLE TO ATTEND 3 HOURS OF TUTORING PER WEEK?
*
Yes
No
WHERE DID YOU HEAR ABOUT OUR PROGRAM?
*
Flyer
Social Media (Facebook, Instagram, Twitter)
Buffalo Employment and Training Center (BETC)
Other:
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